hypothermia.... cold man
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    hypothermia.... cold man hypothermia.... cold man Presentation Transcript

    • ?Alive
?Dead……….Hypothermia
 Dr
Wahid
Altaf
 Ireland

    • Cold
Man

    • MRN
834269
J.
P.
S
 D.
O.
B.
7/2/1984,
25
y
old
 5/3/9

 Previously
...
 Found

at
0722
am
 Recently
released
from
prison
 
collapsed,
unconscious
by
passer
by
 
History
of
depression,
anxiety
 
 
in
St
Finbarr’s
(Glasheen)
graveyard
 Last
seen
evening
before
at
5.30
pm,

 Ambulance
arrived
0728,
 parents
pills
missing
–
 
 
aspirin,

 
Groaning
in
ambulance,

 
 
plavix,

 

GCS
3/15,
 
 
lipitor,
 

 
‘pulse
present
but
irregular’
 
 
tritace,
 

 
Pupil
size
4/8
bilateral.

 
 
emcor,
 

 
 
paracetamol.
 Arrive
in
CUH
0747
 
Smell
of
alcohol
off
breath,
 
Abrasions
on
forehead,
leQ
arm,
leQ
leg

    • A&E
0747
 Unresponsive,
pulseless,
asystole,

 Bloods
in
A&E
 TIME
 0804
 Pupils
non
reacVng
&
dilated
 PaO2
 3.0
 Abrasions
on
head
 PaCO2
 13.4
 Na

141
 Rectal
temp
20oc
 K
 
5
 pH
 7.13
 0820
rectal
temp
22.2oc
 Cl
 
105
 Lactate
 3.1
 9
mg
adrenaline
between
0755
and
0835,
CPR,

 (0.5‐2.0)
 intubaVon,
venVlaVon(vomitus
noted
in
 Urea
6.9
 Bic
 33
 throat)
 Creat
79
 B
def
 +4.1
 2
L
fluid
given
in
A&E
 Alb

33
 Na(Blood
Gas)
 137
 Catheterised
 AST


46
 K
(Blood
Gas)
 4.7
 Phos
2.03
 Cl(BG)
(98‐107)
 96
 0850
to
theatre
for
rewarming
on
CPB
 Theatre
0850
‐
1230
 CK
 2134
 ECG


na
 Hgb
 14.3
 Glucose
 ?

    • 0900






1000





1100






1200

    • C
 CT
brain
5/3/9
 (contrast)

    • ICU
bloods
 Theatre
 5/3/09
 6/3/09
 7/3/09
 Time
 Day
0
 Day
1
 R.
Fem
A
>
V
CP
Bypass
 1530
 0620
 Hgb
 10.6
 9.9
 Spontaneous
rhythm
at
 WCC
 27.4
 22
 nasopharyngeal
temp
32oC
 plat
 335
 242
 Rewarmed
to
35oC
 INR
 1.2
 1.1
 APTT
 35
 28
 Bilirubin
 7
 6
 ICU

 ALT(4‐45)
 145
 142
 venVlate
 CK
(40‐180)
 3677
 NA
 Cefuroxime
+
metronidazole
 Creat
 43
 88
 R.Basal
consolidaVon

    • 5/3/9
ICU
 ICU
 Date
 5/3/09

(day
0)
 6/3/09
(day
1)
 Time
 1300
 1400
 1600
 1800
 2000
 2200
 2400
 0200
 0400
 0600
 Adrenaline
 16
 14
 14
 12
 12
 12
 12
 10
 6
 off
 MAP
 67
 87
 69
 72
 72
 70
 68
 68
 84
 86
 Urine
ml/ 500
 70
 100
 320
 290
 150
 100
 125
 100
 120
 hr
 Temp
oC
 35

    • TIME
 0804
 1315
 1500
 1700
 0047
 PaO2
 3.0
 13.2
 14
 15.9
 14.2
 PaCO2
 13.4
 10.4
 6.3
 5.5
 4.6
 pH
 7.13
 7.19
 7.34
 7.38
 7.48
 Lactate
 3.1
 1.0
 1.3
 1.6
 1.2
 (0.5‐2.0)
 Bic
 33
 29.8
 25.4
 24.3
 25.3
 B
def
 +4.1
 1.6
 ‐
0.4
 ‐
0.8
 +1.8
 Na(BG)
 137
 140
 139
 135
 139
 K(BG)
 4.7
 4.4
 4.4
 4.0
 3.7
 Cl(BG)
 96
 (98‐107)
 CK
 2134
 Hgb
 14.3
 Glucose
 8.1
 8.5

    • 5/3/9
cxr

    • Chest
x
ray
ICU
6/3/9

    • Cxr
8/3/9

    • Conundrums
 Who
gets
hypothermia
 Rewarming 
passive
 
induced
 
 
 
acVve
 
accidental
 How
to
rewarm
 
problems
encountered
 Hypothermia 
duraVon
of
exposure
 
 
 
temp
at
discovery
 Rate
of
rewarming 

 
fast
 
slow

‐

risks
of
prolonged
CPR
 ILCOR

special
resuscitaVon
situaVons
 
 




 
poor
cardiac
output
 
 
 

cerebral
hypoxia
 
 
 
#
ribs,
liver,
spleen
 
 
 

 Temperature
at
which
to
stop
rewarming

    • Cooling
down
‐
problems
 Re‐warming
‐
problems

    • Swiss
study
NEJM
1997

    • o
 E

    • Sigaard
Anderson
1962